We report a case of life-threatening hypokalemia in a 28-year-old bodybuilder who presented with sudden onset bilateral lower limbs paralysis few days after his bodybuilding competition. His electrocardiogram (ECG) showed typical u-waves due to severe hypokalemia (serum potassium 1.6？mmol/L, reference range (RR) 3.5–5.0？mmol/L). He was admitted to the intensive care unit (ICU) and was treated with potassium replacement. The patient later admitted that he had exposed himself to weight loss agents of unknown nature, purchased online, and large carbohydrate loads in preparation for the competition. He made a full recovery after a few days and discharged himself from the hospital against medical advice. The severe hypokalemia was thought to be caused by several mechanisms to be discussed in this report. With the ever rising number of new fitness centers recently, the ease of online purchasing of almost any drug, and the increasing numbers of youngsters getting into the bodybuilding arena, clinicians should be able to recognize the possible causes of sudden severe hypokalemia in these patients in order to revert the pathophysiology. 1. Introduction Severe hypokalemia can be life threatening. It can be caused by genuine diseases or iatrogenic. Either way, prompt recognition of the condition and the underlying causes is needed for effective management of the patients. With the ever rising number of new fitness centers recently, the ease of online purchasing of almost any drug, and the increasing numbers of youngsters getting into the bodybuilding arena, clinicians should be able to recognize the possible iatrogenic causes of sudden severe hypokalemia in this group of patients. 2. Case Presentation A 28-year-old Chinese man with good past health and no significant family history presented to the Accident and Emergency Department (AED) due to sudden onset bilateral lower limb paralysis (Medical Research Council power grading 2/5) on August 13, 2013. The patient reported no recent head, neck, or spine injury and remained conscious all along. Physical exam revealed a muscular young man with no features of dehydration, hyperthyroidism, or Cushing’s syndrome. Urgent imaging including plain computer tomography (CT) of brain and X-ray spine showed no abnormality. ECG showed typical u-waves and serum biochemistries came back to show severe hypokalemia (1.6？mmol/L, RR 3.5–5.0？mmol/L) (Figure 1). His serum creatinine, magnesium, thyroid stimulating hormone, and pH levels were all normal. He was therefore admitted to the ICU and was commenced on oral and intravenous
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